Laserfiche WebLink
Sanitary Permit Application Safety&Buildings Division <br /> In accord with Comm 83.2 1,Wis.Adm. Code 201 W.Washington Ave. <br /> See reverse side for instructions for completing this application PO Box 7302 <br /> `*sconsin personal information you provide may be used for secondary purposes Madison,WI 53707-7302 <br /> Department of Commerce <br /> [Privacy Law,s. 15.04(1)(m)] (Submit completed form to county if not <br /> state owned. <br /> Attach complete plans to the county copy only)for the system,on paper not less than 8-1/2 x 11 inches in size. <br /> County State Sani Permit Number ❑C k if vision t previo application State Plan D.Num er <br /> uC-4 0 <br /> I.Application Information-Please Print all Information LLocation: <br /> Property Owner Named Property Location <br /> (_4A 't /c//yL CY fE 1/4 NC A,S.S_ T-7,Y N, S or <br /> Property Owner's Mailing Address Lot Number Block Number <br /> 9 yi ruo%L Fzf C. 4� <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> II.Type o uilding:Icheck one) ❑City <br /> CT�_1 or 2 Family Dwelling-No.of Bedrooms: ❑Village <br /> ❑ Public/Commercial(describe use): fa Town of <br /> ❑ State-Owned `a /-6)Ile <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) Near3st Road <br /> kjAaL,L /?d- <br /> A) 1. "ew System 2. ❑Replacement 3. ❑Replacement of 4. ❑Addition to Parcel Tax Number(s) <br /> S stem Tank Only Existin S stem 0 3 (!'O�U0 <br /> B) Permit Number Dale Issued <br /> ❑A Sanitary Permit was previously issued <br /> IV.Type of POWT System: (Check all that apply) --// <br /> ❑Non-pressurized In-ground Ovlound ❑Sand Filter ❑Constructed Wetland <br /> ❑Pressurized In-ground ❑Holding Tank ❑Single Pass ❑Drip Line <br /> ❑At-grade ❑Aerobic Treatment Unit ❑Recirculating ❑Other: <br /> V.Dispersal/Treatment Area Information: <br /> 1.Design Flow(gpd) 2.Dispersal Area 3.Dispersal Area 4.Sois./day/sq.ft.) (Min./inch) <br /> Application 5.Percolation Rate 6.System Elevation 7.Final Grade <br /> Required Proposed Rate(Gal ./inch) Elevation <br /> o -- ADO . ?00 io/, y <br /> VI.Tank Capacity in Total #of Manufacturer Prefab Site Steel Fiber- Plastic <br /> Information Gallons Gallons Tanks Con- Con- glass <br /> New Existing crete structed <br /> Tanks Tanks <br /> SP /jC 000 n'Jrferi <br /> /ti�,r boa foo l r�r11 <br /> II.Re ponsibility Statement <br /> I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(print) Plumber's Signature(no stamps): MP/MPRS No. Business Phone Number <br /> �a _�� /J/'tea 7C 9S— <br /> Plumber's Address(Street,City,State,Zip Code) <br /> VIII.County/Department Use Only <br /> ❑Disapproved Sanitary Permit Fee(Includes Groundwater Date Issued Issuin ent stamps) <br /> Approved ❑Owner Given Initial Adverse Surcharge F <br /> Determination <br /> IX.Conditions of Approval/Reasons for Disapproval: <br /> SBD-6398 R07/00 <br />